RSI w/ lildo?

[jroyster06]

We had a stroke pt the other day with a gcs of about 5. While we were waiting on the helicopter, we RSI'd a pt w/ Sux, Etomidate, Fentanyl. . . .and lido? We didnt push Vex b/c the Helicopter landing we knew prefered a different long term paralytic. But, why did the lead medic push the Lido? Her cardiac rythm did not indicate lido

 

[FlightMedicHunter]

Lidocaine is thought to reduce intracranial pressure (ICP). If you had to RSI a stroke patient that probably means that the stoke was suspected to be hemorrhagic in nature and if it was hemorrhagic in nature then ICP would surely be suspected.

 

[jroyster06]

We were suspecting a hemmoragic because of the rapid LOC. How does lido reduce ICP? also PHI called us back once they were downtown. It wasnt a hemmoragic, we are still waiting to hear back if it was ischemic or something totally different.

 

[Outbac1]

Lidocaine has long been used, (and studied), prelaryngoscopy to blunt the stimulant effects of the procedure. The goal is to decrease the rise in HR, B/P, and ICP caused by laryngoscopy. There have been many studies trying to measure its effect. Some say it works well and some say there is no change. Some services will use it as it generally is not found to cause harm if not benificial to the pt. Their theory is it doesn't hurt and may help so lets use it.
We don't use it for this here.
I'm surprised you were not taught about it during your Paramedic training. I know we had a number of discussions about it in mine. Take an hour an Google it. There is lots to read. Here is a small sample.

http://www.springerlink.com/content/02864362918673lq/

http://www.lotsofessays.com/viewpaper/1693507.html

http://oai.dtic.mil/oai/oai?verb=getRecord&metadataPrefix=html&identifier=ADA426711

http://www.ncbi.nlm.nih.gov/pubmed/3354875

http://www.ncbi.nlm.nih.gov/pubmed/8872690

http://emj.bmj.com/content/18/6/453.abstract

 

[FlightMedicHunter]

How does lido reduce ICP?

HA! That's a million dollar question right there...Just like with many other drugs that paramedics use there really is no clinical evidence that Lidocaine improves neurological outcome in patients. There have been studies that have shown Lidocaine to reduce ICP however, none of those studies have proven that this small reduction in ICP improved the neurological outcome of the patient.

 

[jroyster06]

Thanks guys for all of the great replys. Thanks for the links on google. Great information here as always.

 

[18G]

In my program RSI was not taught so we did not go over in detail the different meds used and how they worked. We touched on it and that was it. Ground services here don't RSI so I can understand why jroyster06 may not have been familiar with lidocaine in the setting of RSI.

 

[medic86]

I see someone mentioned that lido will counteract the rise in heart rate?? You shouldn't see a rise in HR as laryngoscopy tends to actually lower heart rate. That's why we use atropine around here as a premedication to anesthesia induction.

 

[jroyster06]

Yall premed with atropine? That seems incredibly odd to me. I mean you can cause a vagal response but even still we just wait till after make sure they dont go down to a dangerous bradacardic rate and if so then we treat the rate. Most pts that get RSI'd really dont need and additional increase in rate if it can be helped.

 

[usalsfyre]

...anesthesia induction...

So just to be clear, what EMS is doing is not induction of anesthesia. What we do is procedural sedation to place an endotracheal tube. It's a bit of a semantic difference per say, however anesthesia providers are not limited to a certain sequence of events/medications and are free to administer a variety of medications as is approprite to the patient. In addition the education involved in becoming an anesthesia provider is FAR, FAR in excess of what the average medic receives. It's fair to say the average anesthesia provider probably forgets more in a career than the average medic will know.

I say all this not to bag on medics, but to keep EMS providers from embarasing themselves. Tell another medical provider your inducing anesthesia and you'll probably be dismissed and laughed at behind your back.

 

[FlightMedicHunter]

Yall premed with atropine? That seems incredibly odd to me. .

It is standard practice for most RSI protocols to premedicate with atropine in pediatrics. Pediatrics have a wicked tendency to brady down during RSI, especially if someone is not smooth with the laryngoscope. I have not seen this applied to adults but it could be instituted just as a precaution.

 

[usalsfyre]

Yall premed with atropine? That seems incredibly odd to me. I mean you can cause a vagal response but even still we just wait till after make sure they dont go down to a dangerous bradacardic rate and if so then we treat the rate. Most pts that get RSI'd really dont need and additional increase in rate if it can be helped.

Premediaction with either one is really pretty old medicine. Lidocaine as was noted before has no PROVEN benefit. Atropine used to be required in pediatric patients, but the AAP has now recomended it only be administered routinely to patients who are under two. The current thinking I've seen is to treat vagally caused bradycardia PRN with atropine and blunt any potential sympathetic stimulation (and resulting rise in ICP) with gobs of opiates.

 

[Smash]

There is some contention now that atropine premedication in pediatric patients is not as necessary as was previously thought. When intubating adults I will always have atropine drawn up. It's not just manipulation of the larynx that may cause brady bradycardia but also the suxamethonium as well.

As for lidocaine, I had thought that had gone away a long time ago due to lack of evidence. It's obviously is one of those tenacious ideas that lodge in brains and won't let go.

 

[mikie]

Nobody ever hear of LOAD?

We learned about RSI a few weeks ago; were taught the acronym LOAD for the Pretreatment phase.

Lidocaine (1.5 mg/kg)
Opioid
Atropine (regional protocol: <1y/o; 0.02 mg/kg)
Defasiculating Agent (1/10th therapeutic dose)

 

[medic86]

I see your point. And don't get me wrong, I wasn't saying we are anesthesiologist or even close to that, however, if you have RSI protocols, you do induce anesthesia. Induce means to make something happen. Anesthesia is the state of being unaware of what is going on or simply having no memory of the events that happened. So even a simple procedure using versed, such a cardioversion, could be considered induction in my opinion.

 

[jroyster06]

Basically what im gathering and a general impression is Lidocane was given in my case for a reduction in ICP for our stroke pt. Some still use it every time although there i no solid evidence for any of it. lol

 

[Smash]

We learned about RSI a few weeks ago; were taught the acronym LOAD for the Pretreatment phase.

Lidocaine (1.5 mg/kg)
Opioid
Atropine (regional protocol: <1y/o; 0.02 mg/kg)
Defasiculating Agent (1/10th therapeutic dose)

I think most of us will have heard that acronym. However, aside from opioids, which typically are part of the induction as opposed to pretreatment, there is no evidence for the rest them. Lidocaine and atropine have been discussed. Defasciculating doses of non-depolarizing agents is a nice idea, but also doesn't work. It is meant to reduce muscle soreness in patients undergoing anesthesia, but hasn't been shown to work particularly well. The setting of an elective patient in a controlled environment who will be woken up in an hour or two is also very different to the setting of the head injured patient in the field and the two have very different priorities.

 

[MrBrown]

We had a stroke pt the other day with a gcs of about 5. While we were waiting on the helicopter, we RSI'd a pt w/ Sux, Etomidate, Fentanyl. . . .and lido? We didnt push Vex b/c the Helicopter landing we knew prefered a different long term paralytic

A different one? Like what, pancuronium?

Oh BTW bro it's vecuronium not vexamethonium .... just sayin

Now it is good to see you called the helicopter, Brown was getting bored sittign there all day

We learned about RSI a few weeks ago; were taught the acronym LOAD for the Pretreatment phase.

Lidocaine (1.5 mg/kg)
Opioid
Atropine (regional protocol: <1y/o; 0.02 mg/kg)
Defasiculating Agent (1/10th therapeutic dose)

Brown must once again smash his head on the wall in blind rage .... enough with the freaking acronyms and cookbook Parathinktheyare recipies!

I see your point. And don't get me wrong, I wasn't saying we are anesthesiologist or even close to that...

What, are you saying Brown really doesn't deserve to have this "DOCTOR" jumpsuit? Now, you're not saying he just bought it off the internet are you?

...if you have RSI protocols, you do induce anesthesia. Induce means to make something happen. Anesthesia is the state of being unaware of what is going on or simply having no memory of the events that happened. So even a simple procedure using versed, such a cardioversion, could be considered induction in my opinion.

Brown reckons you are kind of correct however gangsta bootleg styles our bit of midaz or ketmaine induced "anaesthesia" is ... not sure the Consultnat Anaesthetist would agree with us here.

 

[medic86]

I am so confused?? Are you talking in 3rd person?? What are you saying?

 

[usalsfyre]

If it's PHI Texas the paralytic of choice is Rocc. However I wonder why anybody is doing routine long-term paralysis instead of adaquate sedation/pain control post-intubation (hell I wonder why anybody is using succs to begin with but that's a different issue all together).

I think Browns blind rage has to do with how paramedic students are being taught easy to remember accronyms instead of being given a real and deep understanding of what each drug in the premedication sequence is trying to accomplish. This creates a "fill in the check box" type of afair, when that's the last thing that should be happening in a complicated, high risk procedure. But I can't speak for him and I could be wrong.